A nurse is caring for a client who is 1 day postoperative following an open thoracotomy. The client is receiving oxygen mist at 40% by face tent. The client's SPO2 is 89-96%. ABG results are: pH 7.31, PaO2 93 mm Hg, PCO2 5O mm Hg, HCO3 25 mEq/L. Which of the following is an appropriate action by the nurse?

Position the client prone and have the respiratory therapist perform postural drainage.

Place the client in high-Fowler's position and encourage the use of incentive spirometer and coughing.

Increase oxygen to 70%.

Switch oxygen to a nonrebreather mask.

Answer and Explanation

The Correct Answer is B

A. Prone positioning and postural drainage are typically not appropriate interventions for a client 1 day postoperative following an open thoracotomy, as this could place stress on the incision site and cause discomfort or injury.

B. High-Fowler's position facilitates lung expansion, which can improve ventilation and oxygenation. Encouraging the use of an incentive spirometer and promoting coughing helps clear secretions and expand the lungs, addressing the mild respiratory acidosis indicated by the ABG results (pH 7.31 and PaCO2 50 mm Hg).

C. Increasing oxygen to 70% is not appropriate, as the PaO2 level is within normal limits (93 mm Hg). The client's issue appears to be related more to ventilation (indicated by the elevated PaCO2) rather than oxygenation, so additional oxygen would not address the underlying cause and could lead to oxygen toxicity if used long-term.

D. A nonrebreather mask delivers a high concentration of oxygen, which is not necessary in this case since the client’s PaO2 is already adequate. The primary issue is not a lack of oxygen but rather the retention of CO2, so promoting ventilation and lung expansion through positioning and respiratory exercises is more appropriate.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Intact skin with nonblanchable redness, painful, warm, soft localized area over a bony prominence

Stage 1 pressure injuries are characterized by intact skin with nonblanchable redness over a localized area, typically over a bony prominence like the sacrum, heel, or elbow. The skin may feel painful, warm, and soft to the touch. Nonblanchable redness means that when pressure is applied to the area, the redness does not fade or blanch (turn white). This stage indicates that tissue damage has occurred, but the skin is still intact.

B. Shallow, open, shiny, dry injury, pink-red wound bed without sloughing or bruising: This description is more indicative of a Stage 2 pressure injury, which involves partial-thickness skin loss with an intact or ruptured blister. The wound bed is usually pink or red, and there is no sloughing or bruising.

C. Full-thickness tissue loss, slough and black eschar in wound bed with undermining and tunneling: This description corresponds to a Stage 3 or Stage 4 pressure injury. Stage 3 involves full-thickness tissue loss with visible subcutaneous fat but no bone, tendon, or muscle exposed. Stage 4 involves extensive tissue loss with exposure of bone, tendon, or muscle. Both stages may include slough (yellow or white tissue) and black eschar (hard, necrotic tissue), along with undermining (tissue destruction under intact skin edges) and tunneling (narrow passageways extending from the wound).

D. Full-thickness tissue loss, subcutaneous fat visible, possible undermining and tunneling: This description also corresponds to a Stage 3 pressure injury, as it involves full-thickness tissue loss with visible subcutaneous fat. The mention of possible undermining and tunneling further suggests a Stage 3 pressure injury.

A. How many people live in your home? B. Did you have a recent exposure to Irritants? C. Is nausea associated with your rash7 D. What is your body mass index?

Correct Answer is B

Explanation

A. How many people live in your home?

This question pertains to social and environmental factors but is not directly related to assessing skin inflammation on the chest. While social factors can impact overall health, such as stress levels or exposure to infectious agents, the number of people living in the client's home is unlikely to be directly related to a new skin inflammation unless there are specific circumstances, such as sharing personal care products or close contact with others who have similar skin issues.

B. Did you have a recent exposure to irritants?

This question is highly relevant to assessing a new skin inflammation on the chest. Exposure to irritants or allergens can trigger or worsen skin conditions, such as contact dermatitis or allergic reactions. By asking about recent exposure to potential irritants like new detergents, soaps, fabrics, chemicals, or environmental factors, the nurse can gather important information to identify possible triggers for the skin inflammation.

C. Is nausea associated with your rash?

Nausea is typically not directly associated with a skin rash or inflammation unless there is a systemic condition or allergic reaction causing both symptoms. While it's important to assess for any systemic signs or symptoms that may be related to the skin condition, such as fever or malaise, specifically asking about nausea may not provide relevant information about the skin inflammation on the chest.

D. What is your body mass index?

Body mass index (BMI) is a measure of body weight relative to height and is not directly related to assessing a new skin inflammation on the chest. While obesity or changes in body weight can sometimes contribute to skin issues, such as friction-related dermatitis or hormonal changes affecting skin health, BMI alone is not a primary assessment parameter for localized skin conditions unless there are specific concerns related to weight-related skin problems.

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Naxlex Comprehensive Predictor Exams

What would be considered early signs/symptoms of pressure injury (Stage 1)?

Correct Answer is A

Explanation

A nurse is caring for a client with a new skin inflammation on the chest. Which of the following is an important assessment question to ask the client?

Correct Answer is B

Explanation

A nurse cares for a patient who has a deep wound that is being treated with a wet to-damp (used to be dry) dressing. Which intervention would the nurse include in this patient’s plan of care?

A nurse is caring for a 70-year-old client who has a pressure injury in the coccyx area. The nurse identifies that which of the following factors associated with aging may impact the ability for the ulcer to heat?

A nurse is caring for a client with a pressure injury. Which of the following should the nurse recognize as a priority in the plan of care?

A nurse is assisting in the care of a client who has severe burns. Exhibits Which of the following actions should the nurse take when caring for a client who has severe burns? Select all that apply.

A nurse teaches a patient who is at risk for mild hypernatremia. Which statement does the nurse include in this patient's teaching?

A nurse is caring for a client with a chronic wound. Which of the following is a systemic cause of chronic wounds?

The nurse debriding a burn wound explains that the purpose of debridement is to:

A nurse is caring for a client who is scheduled for abdominal surgery. Which of the following nursing interventions should the nurse include in the preoperative education?